What is the recommended management for a 36-year-old female with a 9-day headache?

Management of 9-Day Headache in a 36-Year-Old Female

For a 36-year-old female with a 9-day persistent headache, first rule out red flag features requiring urgent neuroimaging, then treat acutely with NSAIDs (naproxen 500-825 mg) or triptans (sumatriptan 50-100 mg) while simultaneously initiating preventive therapy given the prolonged duration. 1, 2

Initial Assessment: Rule Out Secondary Causes

The 9-day duration itself is a concerning feature that warrants careful evaluation for secondary headache disorders. 3

Red flag features requiring immediate neuroimaging include: 3

• Focal neurologic signs on examination
• Papilledema
• Neck stiffness
• Sudden onset ("thunderclap" quality)
• Personality changes
• Headache after trauma
• Fever with headache
• Headache worse with Valsalva maneuver or exercise

If any red flags are present, obtain MRI or CT imaging before treating as primary headache. 1, 3 In patients with normal neurologic examination and no red flags, neuroimaging is usually not warranted. 1

For a 36-year-old female specifically, consider: 1

• Relationship to menstrual cycle (menstrual migraine)
• Use of combined hormonal contraceptives (contraindicated if migraine with aura due to stroke risk)
• Pregnancy status (affects medication choices)

Acute Treatment Strategy

First-line acute therapy options: 2

• Naproxen sodium 500-825 mg at onset, can repeat every 2-6 hours (maximum 1.5 g/day) 2
• Sumatriptan 50-100 mg orally (doses of 100 mg may not provide greater effect than 50 mg but have higher adverse event risk) 4
• Combination therapy: Aspirin + acetaminophen + caffeine for moderate-to-severe attacks 2

Add antiemetic 20-30 minutes before analgesic for synergistic effect: 2

• Metoclopramide 10 mg orally
• Prochlorperazine 25 mg orally

If oral therapy fails due to nausea/vomiting, use non-oral routes: 2

• Subcutaneous sumatriptan 6 mg (most rapid and effective, 59% pain-free at 2 hours) 2, 4
• Intranasal sumatriptan 5-20 mg 2

Critical Decision Point: Preventive Therapy is Indicated

A 9-day continuous headache or frequent attacks requiring acute medication more than twice weekly mandates preventive therapy. 1, 2 This patient has already exceeded the threshold for preventive treatment initiation.

First-line preventive medications: 1

• Propranolol 80-160 mg daily (long-acting formulation)
• Topiramate 50-100 mg daily (titrate slowly)
• Metoprolol 50-100 mg twice daily or 200 mg modified-release once daily
• Candesartan 16-32 mg daily

Contraindications to consider: 1

• Beta-blockers: asthma, cardiac failure, atrioventricular block, depression
• Topiramate: nephrolithiasis, pregnancy, lactation, glaucoma
• Combined hormonal contraceptives: migraine with aura (stroke risk)

Evaluate preventive therapy effectiveness at 2-3 months, as oral agents require this duration to demonstrate efficacy. 1

Medication-Overuse Headache Prevention

The most critical pitfall to avoid is medication-overuse headache (MOH), which occurs with acute medication use more than twice weekly. 1, 2 This creates a vicious cycle of increasing headache frequency leading to daily headaches. 2

Limit acute therapy to no more than 2 days per week. 2 If the patient is already using acute medications frequently, consider medication withdrawal while initiating preventive therapy. 5

Medications most likely to cause MOH: 1

• Ergotamine
• Opiates
• Analgesics (including NSAIDs when overused)
• Triptans

Follow-Up and Monitoring

Re-evaluate within 2-3 months to assess: 1

• Attack frequency (headache days per month)
• Attack severity and pain intensity
• Migraine-related disability
• Adverse events from medications
• Adherence to treatment plan

Use headache calendars to track symptomatic days and acute medication use. 1 This requires minimal time commitment if completed only on symptomatic days but provides invaluable data for treatment optimization.

If treatment fails after adequate trial (2-3 months for oral preventives), escalate to: 1

• Second-line agents: Amitriptyline 10-100 mg at night, flunarizine 5-10 mg daily
• Third-line agents: OnabotulinumtoxinA 155-195 units every 12 weeks, CGRP monoclonal antibodies (erenumab 70-140 mg monthly, fremanezumab 225 mg monthly)